Continuing Medical Education (CME)class notes for Western clinicians on the application of Acupuncture for Pain Management. Sponsor: Indian American Medical Association, Tuality Hospital.

1. Acupuncture and Pain Management:
an Integrated Perspective
PK Melethil, L. Ac.
Melethil Acupuncture Services, LLC
Wilsonville, OR 97070

2. Overview
Acupuncture in the context of Traditional Chinese Medicine(TCM)- a
Whole Medical system(NIH).
Basic TCM theory of pain and diagnostics and therapeutics.
Clinical considerations in the use of acupuncture.
Headache, Bi (Arthritic) Syndrome for which recent scientific studies (i.e.,
Evidence Based Medicine) show the value of acupuncture.
Potential applications of acupuncture for surgery and post-surgery
treatments to improve outcomes.
3 case studies
IAMA Fall 2007 Acupuncture and Pain Management

3. Anthropological Record
Archaeological evidence: 10,000+ years.
Ma Wang Dui site: 2,000+ years
– clinical tools, philosophical and qigong manuscripts.
Written Texts: 2,000-3,000 years old.
– Herbal Medicine, Acupuncture, Body work
Medicine guided by empiricism
Daosim, Confucianism, Buddhism
Multiple overlapping and co-existing models
Shared knowledge with Yoga, Ayurveda (India)
Greek Influences
Conversations between Huang Di and Chih-Po
IAMA Fall 2007 Acupuncture and Pain Management

4. Background
• Harmony and Balance
• Movement of Qi and Blood
12 Primary Meridians- 6 on each side (symmetry)
8 Secondary (Extraordinary) Meridians
• Acupuncture Points (400-500 x 2)
Jing-Luo Network of points
analogy: a river and its tributaries, a net
Variable size, shifting locations
Ah-shi points
• Mechanism of Action- Contemporary Ideas
• Conductivity gradients (Prognos)
Electrochemical gradients
• Optical/Thermal gradients
• Acoustics- variations in visco-elastic properties of tissues
IAMA Fall 2007 Acupuncture and Pain Management

5. TCM Zang-Fu (organ networks) and their connectivity based on classical texts such as
the Huang Di Nei Jing- The Yellow Emperor’s Canon of Internal Medicine. In some
TCM models, Qi flows through these 12 organ networks every 24 hours with each
organ being assigned a 2 hour window when its Qi is at its peak. Qi flows out from the
torso to the upper extremity and back followed by a circuit through the lower extremity
and the cycle continues again.
Yin Yang Comments*
Lung Large Intestine Upper Body,
(3-5 A.M, Arm-Taiyin) (5-7 A.M., Arm-Yangming) Metal
Spleen Stomach Lower Body,
(9-11 A.M., Leg-Taiyin) (7-9 A.M., Leg-Yangming) Earth
Heart Small Intestine Upper Body,
(11 A.M.-1 P.M., Arm-Shaoyin) (1-3 P.M., Arm-Taiyang) Fire
Kidney Urinary Bladder Lower Body,
(5-7 P.M., Leg-Shaoyin) (3-5 P.M., Leg-Taiyang) Water
Pericardium Triple Warmer Upper Body,
(7-9 P.M., Arm-Jueyin) (9-11 P.M., Arm- Shaoyang) Fire
Liver Gall Bladder Lower Body,
(1-3 A.M., Leg-Jueyin) (11P.M–1 A.M., Leg-Shaoyang) Wood
* regions of the body associated with the primary channels of the12 Zang-Fu organ
networks and their 5 Phase/Element associations in TCM.
IAMA Fall 2007 Acupuncture and Pain Management

6. TCM Models of Pathology- “Disharmony”
Models of Pathology
Cold Induced Illnesses
Progresses from External (Yang) to Internal (Yin) channels- 6 Levels
Zang-Fu Theory
Based on Organ Disorders (Meridians)
Warm-Febrile Diseases
Progresses from Outer to Inner layers
Models: Triple Burner, 4 Levels
Causative factors
External /Environmental Pathogenic Influences
Damp, Cold, Heat/Fire, Wind, Dryness, Summer heat ACUTE
Internal Pathogenic Influences
Emotions (Stagnation) CHRONIC
Phlegm << Body Fluids + “Heat”
Deficiency Patterns
IAMA Fall 2007 Acupuncture and Pain Management

7. Diagnostics & Therapeutics
• Diagnostics
Interview
Palpation
Tongue
Pulse
• Therapeutics
Acupuncture
TuiNa (Medical Massage)
Internal Medicine Diet/Nutrition, Herbs, Minerals, Animal products
Qigong, Tai Ji Quan, meditation (Exercises)
IAMA Fall 2007 Acupuncture and Pain Management

8. Ma Wang Dui- Ancients Qi Gong
IAMA Fall 2007 Acupuncture and Pain Management

9. Pain
• Stagnation/Anisotropy
Qi, Blood
• Bi Syndrome (external pathogen)
• Types of pain (paresthesias)
Sharp, piercing
Dull, throbbing
(Heaviness)
(Numbness)
IAMA Fall 2007 Acupuncture and Pain Management

10. Advantages of Acupuncture
Simple, Gentle
Painless (200-300 mm,
single-use needles)
Safe, Minimal side effects
Reduced use of narcotics &
other medications
Effective, Economical
IAMA Fall 2007 Acupuncture and Pain Management

11. Veterinary Acupuncture
Equine, etc.
No ‘placebo effect’
Highly effective
Well-established
veterinary practices in
China & US
IAMA Fall 2007 Acupuncture and Pain Management

12. Microsystem Acupuncture
“Holographic” Models
• Ear
Developed by French MD (1950s)
Paul Nogier
• Scalp
Jiao, Zhu models
• Feet
Reflexology
TuiNa
IAMA Fall 2007 Acupuncture and Pain Management

13. Needle Techniques
• Depth of insertion
• Angle of insertion
• Feeling the Qi
• Viscoelastic aspects of tissues
• De Qi and propagated sensations
• Reinforcing & Reducing techniques
• Electro-acupuncture
Low frequency ( <10 Hz) and high frequency (~100 Hz)
IAMA Fall 2007 Acupuncture and Pain Management

14. Arthritis (“Bi”) Syndromes
EARLY STAGE: EXCESS PATTERN >>>>> LATE STAGE: DEFICIENCY PATTERN
6 Constitutional Patterns
• Wind (Wandering) Bi Migrating pain in muscles, joints
• Cold (Painful) Bi Fixed pain, Alleviated by warmth
• Damp (Fixed) Bi Marked soreness, numbness, heaviness
• Heat Bi Swelling, soreness & pain w local redness
• Stagnation of Blood & Phlegm
Swelling, rigidity, deformity joints & limited ROM
• Liver & Kidney Deficiency
alleviated by rest; sore and weak low back, knees
“Acupuncture Found To Be of Benefit in Knee Osteoarthritis”
http://nccam.nih.gov/news/newsletter/2005_winter/acupuncture.htm
Acupuncture for knee osteoarthritis--a randomised trial using a novel sham. Acupunct Med. 2006
Dec;24 Suppl:S7-14. Manheimer E, Lim B, Lao L, Berman B.
IAMA Fall 2007 Acupuncture and Pain Management

15. Headache (9 Constitutional patterns)
E External, Internal (Stagnation, Deficiency)
x
t
e • Wind Heat acute onset, yellow nasal discharge, sore throat, red
r
n
a
• Wind Cold acute onset, stiff neck, no thirst
l
• Wind Damp fuzzy head, chest oppression, heavy feeling
I
n • Liver Yang Rising irritable, restless, insomnia, sore low back/knees
t
e • Qi Deficiency positional HA, worse with stress or lassitude
r
n • Blood Deficiency dizziness, palpitations
a
l • Turbid Phlegm nausea, vomit with sputum, dizziness
• Blood Stagnation stabbing pain, prolonged & fixed, history of trauma
• Kidney Deficiency dizziness, tinnitus, “empty” head feeling
IAMA Fall 2007 Acupuncture and Pain Management

16. Acupuncture for Post-operative pain
• Differentiation (8 principles, 5 Elements, 4 Levels, 3 Burners)
• Before the operation (improve outcomes)
Constitutional issues, Shen
• After the operation (move Qi & Blood, tonify)
External Pathogenic Influences (cold, dryness)
Emotions
Nature of pain
Affected Organs
IAMA Fall 2007 Acupuncture and Pain Management

17. Case Studies
• Anesthesia (Surgery)
Acupuncture was successfully used as the sole means of anesthesia during a surgery for
breast reconstruction following cancer, and also substantially facilitated pre-operative
procedures. The combination of eastern and western medicines substantially reduced patient
disability, hospitalization and cost.
• Low back (Lumbar) Pain
male, 40 , suffering from low back pain, unable to sit for more than 2 hours at a time.
Reported as possible effects of sports injury from 20 years ago. Assess- tight IT band.
Dx- Qi/Blood stagnation in GB, Bl channels. Tx- acupuncture and electro-acupuncture, GB
and Bl channels. Condition resolved in 4 treatments, include exercise to stretch IT band;
follow-up after one month indicated that pain had been resolved completely.
• Post-Shingles Paresthesia
female, 93, suffering from limited vision, post herpetic uveitis (Western Dx) and paresthesia
around L eye. No improvements in 2 months w acyclovir tablets, ciproflaxin eye drops.
Dx- Damp Heat-GB channel, Qi/Blood deficiency. Tx: acupuncture (local/distal), GB channel
and TuiNa; significant improvement (uveitis) in 4 visits and vision in 9 visits, confirmed by
opthalmologist. Patient reports increased energy w ongoing treatment.
IAMA Fall 2007 Acupuncture and Pain Management

18. Acupuncture for Breast Reconstruction Surgery
Photo provided by Roger Lore, DAOM
IAMA Fall 2007 Acupuncture and Pain Management

19. Treatment Approaches
• Local and Distal points
• Channel based
• Complementary (Yin/Yang) Channel based
• Microsystem Techniques
• External vs Internal Syndromes
• Frequency of Treatments
IAMA Fall 2007 Acupuncture and Pain Management

20. Other Techniques for Pain
• TuiNa
Orthopedic massage and muscle alignment techniques
• Qigong
• Internal Medicine
Over 1000 herbs in TCM pharmacopoeia
formulas are well-tested, hundreds to thousands of years old
Herbs are classified by
their flavor and nature
the channels/organs they act upon
the specific actions on a given organ
e.g., Ju Hua (chrysanthemum) is considered to be slightly cold, sweet, bitter, and
acrid, enters the Liver channel and soothes the eyes. Its’ found in formulas used to
treat Wind Heat- fever w chills, aversion to cold, sore throat.
Current herbal products manufactured under cGMP guidelines
IAMA Fall 2007 Acupuncture and Pain Management

21. Further Readings
• The Web That Has No Weaver, Ted Kaptchuk
• Medicine in China, Paul Unschuld
• Acupuncture: A Comprehensive Text, John O’Connor, Dan
Bensky
• The Practice of Chinese Medicine, Giovanni Maciocia
• The Management of Post-operative Pain with Acupuncture,
Sun Peilin
Acupuncture of chronic headache disorders in primary care: randomised controlled trial and
economic analysis. Health Technol Assess (UK) 2004;8(48). VickersAJ, Rees RW, Zollman CE,
McCarney R, Smith CM, Ellis N, Fisher P,Van Haselen R, Wonderling D and Grieve R.
Designing an acupuncture study: the nationwide, randomized, controlled, German
acupuncture trials on migraine and tension-type headache. J Altern Complement Med. 2006
Apr;12(3):237-45. Molsberger AF, Boewing G, Diener HC, Endres HG, Kraehmer N, Kronfeld
K, Zenz M.
IAMA Fall 2007 Acupuncture and Pain Management